Patient Resources

MyChart Registration & Caretaker Forms

Thank you for your interest in MyChart®, an easy-to-use internet tool that provides you quick and secure online access to your Austin Regional Clinic health information from anywhere at any time. To register for access to your health information in MyChart® or to register for caretaker access to your loved ones' health information in MyChart®, please complete the appropriate MyChart® form(s) below.

For your convenience we provide our patient forms online. Please bring the completed form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

MyChart Registration Forms: use the PDF forms below to gain access to your medical information using MyChart.

  • MyChart Adult Registration Form (18 years old or older)
    Fill out this form to access your Austin Regional Clinic health information online from anywhere at any time.

MyChart Caretaker Forms: use the PDF forms below to gain access to your child or a loved one's medical information using MyChart.

  • MyChart Child Caretaker Form
    Fill out this form to request access to your child's MyChart record through age 17 (some limitations apply depending on the age of the child, please see the form for detailed information).
  • MyChart Adult Caretaker and Authorization ROI Form
    Fill out this form to request access to the MyChart record of an adult whose medical care you help manage. For access to be granted, the patient must complete both pages of the form including the Authorization for Release of Medical Information section which will authorize another adult to access your medical information in the MyChart record.



We Want To Hear From You

*By using this form to communicate with austin Regional clinic (ARC), the information will be transferred over the internet. ARC uses Transport Layer Security (TLS) encryption in order to secure the information you send to us over the internet. There may be times when we cannot respond to your request in email format and another method of communication will be used. For your privacy, please consider the information you include, and who, besides you, may have access to your email account.